Many years ago, as I became educated on "Vision 2020," I almost immediately thought, "Well, what of the PTAs?" Do they get lost in the rearview mirror? Do we actually believe, if doctoral-level education and application is needed, and the gap between a two-year education and a seven-year education widens, that the role of the PTA doesn't matter? As an example, master's-educated physician assistants (PAs) would likely be far less assistive to the MD/DO if their education was of the two-year variety. Their scope of practice would be less encompassing, and reimbursement for services would likely be more limited.
What actually underlies the need for at least a closer look at PTA education are two primary questions:
1. Does the PTA currently meet the needs of adequately/appropriately assisting the PT in application of therapeutic services?
2. Are the needs of patients being met adequately/appropriately by the PTA?
Task Force
In 2007, the APTA convened a task force to investigate. The outcome resulted in the creation of the minimum skills needed pertaining to PTA clinical function. At that time, the AAS/AS degree was adequate and served the needs of the therapist and the patient. In 2009, according to Janet Crosier, PT, DPT, MEd, director, physical therapist assistant services of the APTA, the APTA Board of Directors' (BOD) position was thus: 1) community colleges presently provide 80-plus percent of the education required; 2) the PTA scope of work has not expanded sufficiently to warrant expansion of the education; and 3) any additional tasks/responsibilities can be learned on the job and/or via CEUs post-licensure attainment.
That position was noted in Section E-21, adopted April 2010, of the Accreditation Handbook. The PTA Caucus and the Advisory Panel of PTAs, however, may not have been in complete agreement with the position and degree limitations imposed by the Commission for Accreditation of Physical Therapy Education (CAPTE). When PTA educators are polled, there is general consensus that the PTA program is as filled with didactic and clinical applications as it can be.
However, there does not seem to be total agreement among these educators about whether the degree needs to move on to a baccalaureate level. Readers are advised to peruse RC-3-11 and RC-4-11 through RC-12-11 draft related to the APTA's position on PT practice under new health care delivery and payment systems. Dr. Crosier noted that the BOD-appointed Health Care Professionals and Personnel Involved in the Delivery of Physical Therapy Task Force has seven charges from the APTA's BOD, and one is: "Investigate changes to the educational preparation and scope of work of the PTA." (www.apta.org/Policies/Updates/2011FAQ/)
Addressing Points
The APTA BOD position makes valid points. However, I will briefly address those three points in the BOD position as I'm sure they have influence with the authoritative actions on education by CAPTE.
The first point seems a bit tepid, as one should not find the reason for continuing to carry on education at an AAS level contingent on the fact that community colleges presently grant more than 80 percent of PTA degrees. As noted, the curriculum is already bursting at the seams, with some programs I've looked at requiring as many as 70 credit-hours of curriculum in order to attain the degree.
The need for program expansion has arrived and the aspects of maintaining a "two-year" degree over the course of three years of community college education does not seem beneficial to the student, nor fiscally responsible for a community college in relationship to the students it serves.
Point two seems to turn a blind eye to the fact that the APTA Vision for 2020 is what it is. We have recognized, for the most part, that our field needs an expanded education inclusive of radiography, pharmacology, differential diagnosis, complementary medicine, research and evidence-based practice.
It is difficult to imagine that "doctors of physical therapy" could have assistants who were not aware of, and further educated on, similar issues of patient care and physical therapy practice.
Point three alludes that post-degree education can take the place of formal didactic and clinical requirements. In some cases, it may even be superior from a practicality viewpoint. However, imagine if all of education was nothing but on-the-job training and continuing education format. The gaps in knowledge, the decreased breadth and depth of theory and application, and the professionalism lacking would likely be quite evident.
Knowledge Gained
A four-year degree is superior to a two-year degree often because of the intellectual maturation process and knowledge gained that broadens one's viewpoints, analytical skills and decision-making.
In addition, we can't help but believe some bias may exist when polling educators who administrate and instruct in such programs since 80-plus percent occur at the community college level. It would be difficult for a community college to initiate four-year degrees because that is not their mission. Hence, they would possibly lose those programs over time as the degree moved forward.
I note that CAPTE must have recognized the potential for growth in PT education very early on, as no ceiling for PT education ever existed when it became a four-year degree. Why we should limit the amount of education for our PTA brethren does not seem to be forward-thinking.
If CAPTE would consider lifting the cap on PTA education and allowing at least optional baccalaureate opportunities with correlative hybrid programs (e.g., exercise physiology, athletic training, recreational therapy, kinesiology), it would benefit patient care, those who chose the PTA path and the therapists who use PTA services. This seems a reasonable first step.
Scope of Practice
The APTA has stated that PTAs' scope of practice has not expanded enough to warrant further education; however, the APTA has instituted the "Recognition of Advanced Proficiency for the Physical Therapist Assistant" with some fairly rigorous criteria to be met. If the APTA felt that PTA education was quite enough as is, why institute a greater benchmark? Of course, because that benchmark enhances a PTA's skills, it is commendable that such an aspect is offered. But why not make a more rigorous collegiate education available, and have the licensure exam reflect it? In essence, what is being said is that "adequate education is good enough."
One of my professors in PT school once noted that "good" is the enemy of "great." I would hope that the status quo, "adequate" education and "good enough" are not really what we are striving for in any aspect of physical therapy education, whether pertaining to therapists or assistants.
A point to be pondered as our health care system continues to go through significant change is reimbursement. I offer a quote by Mary Beth Chambers, manager of corporate communications for Blue Cross/Blue Shield of Kansas: "Our tiered-reimbursement philosophy is based on paying the highest percentage of our maximum allowable payment to those with the highest level of knowledge, education or training."
That can certainly affect any private practice, rural areas of service and hospital-based PT practice secondary to either requiring greater supervision for PTAs (due to their education or training), a decrease in reimbursement when treatment is rendered by a PTA, and/or an increased need for "line-of-sight" supervision as well as a decrease in the number of PTAs supervised by a PT.
Adaptability Emphasis
J.T. Thomas, MSPT, coordinator of sports medicine at Wheeling Hospital in Wheeling, WV, noted that PTAs who have additional degrees such as athletic training or exercise physiology are of greater assistance across a wider range of clinical and athletic populations when it comes to pathologies, therapy and strength and conditioning.
Julie High, PT, MS, a PTA program director in St. Louis, stated, "We need studies investigating patient outcomes with and without utilization of the PTA. I think these studies need to be conducted before we decide the AAS terminal degree is not enough. I am all about the PTA serving the needs of the PT, but most importantly, it should be about the patient."
Beyond the aspect of service the PTA provides for both PTs and patients, the PTA would personally benefit from attaining a baccalaureate degree in that it would allow for immediate or future options in terms of application to PT school, medical school, any clinical doctoral program, or a graduate program of choice. Certainly when choosing a degree path as one looks to future options, a BS or BA would be superior to an AAS. At that point, one could choose to gain licensure and become gainfully employed, work part-time while attaining a graduate degree, or immediately move on to graduate training or entry-level doctoral training.
In addition, a hybrid program would offer an inside view of what advanced education in the co-existing training might offer (e.g., exercise physiology, athletic training). In closing, I note that diversification has rarely been a bad thing since, contrary to Darwinian thought, survival does not actually go to the strongest, but generally to the most adaptable.
J. Lance Tarr is owner/operator of Functional Physical Therapy LLC and assistant professor/director of the exercise physiology program at West Liberty University, West Liberty, WV.